Transcript Welcome to ICD-9 Coding Part 3

Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
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Certain Conditions Originating in the Perinatal Period
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This chapter classifies conditions that begin during the Perinatal period
even if death or morbidity occurs later.
The Perinatal Period is defined as the period of time occurring
before, during and up to 28 days following birth.
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These codes are used to classify causes or morbidity and
mortality in the fetus or newborn and should never be used
on the mother’s coding profile.
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Additional codes can be used to further specify the newborn’s
condition.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules
1) Chapter 15 Codes
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are never for use on the maternal record.
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Codes from Chapter 11, the obstetric chapter, are
never permitted on the newborn record.
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Chapter 15 code may be used throughout the life of
the patient, if the condition is still present.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules (Cont.)
2) Sequencing of Perinatal Codes
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Codes from Chapter 15 should be sequenced as the
principal/first-listed diagnosis on the newborn
record, with the exception of the appropriate V30
code for the birth episode, followed by codes from
any other chapter that provide additional detail.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules (Cont.)
2) Sequencing of Perinatal Codes
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The “use additional code” note at the beginning of
the chapter supports this guideline.
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If the index does not provide a specific code for a perinatal
condition, assign Code 779.89, “Other specified conditions
originating in the perinatal period”, followed by the code
from another chapter that specifies the condition.
Codes for signs and symptoms may be assigned
when a definitive diagnosis has not been established.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules (Cont.)
3) Birth process or community acquired conditions
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If a newborn has a condition that may be either due
to the birth process or community acquired and
the documentation does not indicate which one, the
default is due to the birth process and the code from
Chapter 15 should be used.
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If the condition is community-acquired, a code from
Chapter 15 should not be assigned.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules (Cont.)
4) Code all clinically significant conditions
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All clinically significant conditions noted on routine
newborn examination should be coded.
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A condition is clinically significant if it requires:
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clinical evaluation
therapeutic treatment
diagnostic procedures
extended length of hospital stay
increased nursing care and/or monitoring
has implications for future health care needs
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
A) General Perinatal Rules (Cont.)
4) Code all clinically significant conditions
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Codes should be assigned for conditions that have
been specified by the provider as having
implications for future health care needs.
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Codes from the Perinatal chapter should not be
assigned unless the provider has established a
definitive diagnosis.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
B) Use of Codes V30-V39
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When coding the birth of an infant, assign a code from
Categories V30-V39, according to the type of birth.
A code from this series (V30-V39) is assigned as a
principal diagnosis, and assigned only once to a
newborn at the time of birth.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
C) Newborn transfers
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If the newborn is transferred to another
institution, the V30 series is not used at the
receiving hospital.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
D) Use of Category V29
1) Assigning a code from Category V29
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Assign a code from Category V29, “Observation
and evaluation of newborns and infants for
suspected conditions not found,” to identify
instances when a healthy newborn is evaluated for a
suspected condition, that is determined after
study not to be present.
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Do not use a code from Category V29 when the
patient has identified signs or symptoms of a
suspected problem, code the sign or symptom.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
D) Use of Category V29 - (Cont.)
1) Assigning a code from Category V29
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A code from Category V29 may also be assigned
as a principal code for readmissions or
encounters when the V30 code no longer applies.
Codes from Category V29 are for use only for
healthy newborns and infants for which no
condition, after study is found to be present.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
D) Use of Category V29 - (Cont.)
2) V29 Code on a birth record
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A V29 code is to be used as a secondary
code after the V30, “Outcome of delivery,”
code.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
E) Use of other V Codes on Perinatal Record
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V Codes other than V30 and V29 may be assigned
on a perinatal or newborn record code.
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The codes may be used as a principal or firstlisted diagnosis for specific types of encounters or
for readmissions or encounters when the V30
code no longer applies.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
F) Maternal Causes of Perinatal Morbidity &
Mortality
Codes from Categories 760-763, “Maternal causes of perinatal
morbidity and mortality,” are assigned only when the maternal
condition has actually affected the fetus or newborn.
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EXAMPLE:
CODE DESCRIPTION: Other chronic maternal circulatory and
respiratory disease.
760.3
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
G) Congenital Anomalies in Newborns
For the birth admission, the appropriate code from
Category V30, “Liveborn infants according to type of
birth, should be used,” followed by any congenital
anomaly codes, Categories 740-759.
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Use additional secondary codes from other chapters to
specify conditions associated with the anomaly.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
H) Congenital Anomalies in Newborns (Cont)
1) Assigning codes for conditions that require
treatment.
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Assign codes for conditions that require
treatment or further investigation, prolong
length of stay, or require resource
utilization.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
H) Congenital Anomalies in Newborns (Cont.)
2) Codes for conditions specified as having
implications for future health care needs
Assign codes for conditions that have been specified
by the provider as having implications for future health
care needs.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
H) Congenital Anomalies in Newborns (Cont.)
3) Codes for newborn conditions originating in the
perinatal period
Assign a code for newborn conditions originating in the
perinatal period, as well as complications arising
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during the current episode of care classified in
other chapters, only if the diagnoses have been
documented by the provider at the time of transfer or
discharge as having affected the fetus or newborn.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
I) Prematurity and Fetal Growth Retardation
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Providers utilize different criteria in determining
prematurity.
A code for prematurity should not be assigned unless it is
documented.
The 5th digit assignment for codes from Category 764
and Subcategories 765.0 and 765.1 should be based on
the recorded birth weight and estimated gestational
age.
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
I) Prematurity and Fetal Growth Retardation (Cont.)
A code from Subcategory 765.2, “Weeks of
gestation,” should be assigned as an additional
code with:
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Category 764 and codes from 765.0 and 765.1 to
specify weeks of gestation as documented by the
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provider in the record.
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(Certain Conditions Originating in The Perinatal Period)
760 -779
(EXAMPLE
CODE DESCRIPTION: The physician documented that The
baby is “light–for-dates” without mention of fetal
malnutrition, weighed 1850 grams. The baby was small
for gestational age
1. Slow Fetus Growth – 764.07
2. Unspecified weeks of gestation – 765.20
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Chapter 15
Newborn (Perinatal) Guidelines
(760-779)
J) Newborn Sepsis
Code 771.81, “Septicemia [sepsis] of newborn,” should
be assigned with a secondary code from category 041,
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“ Bacterial infections in conditions classified
elsewhere and of unspecified site,” to identify the
organism.
Do not use a code from Subcategory 995.9, “Systemic
inflammatory response syndrome (SIRS),” on a
newborn record.
A code from Category 038, “Septicemia,” should not be
used on a newborn record.
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Code 771.81 describes the sepsis.
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Main Terms
Newborn (Perinatal) Guidelines
(760-779)
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Newborn
Maternal Condition, affecting fetus or newborn
growth
Premature
Observation
Aspiration
Distress
Prolonged
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(Conditions originating in the Perinatal Period)
760-779 - (EXERCISE)
CODE DESCRIPTION: Fetal and newborn aspiration
770.10
CODE DESCRIPTION: Prolonged gestation of infant
766.22
CODE DESCRIPTION: Cold injury syndrome of newborn
778.2
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(Certain Conditions Originating in The Perinatal Period)
760 -779 - (EXERCISE)
CODE DESCRIPTION: Fetal distress, unspecified as to time
of onset, liveborn infant
768.4
CODE DESCRIPTION: Urinary tract infection of newborn
771.82
CODE DESCRIPTION: Observation for other specified
suspected condition
V29.8
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(Certain Conditions Originating in The Perinatal Period)
760 -779 - (EXERCISE)
CODE DESCRIPTION: Other malpresentation, malposition
and disproportion during labour and delivery
763.1
CODE DESCRIPTION: Neonatal Diabetes Mellitus
775.1
CODE DESCRIPTION: Intestinal obstruction due to
inspissated milk.
777.2
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(Certain Conditions Originating in The Perinatal Period)
760 -779
(CASE STUDY 1)
CODE DESCRIPTION: A child with Cockayne’s Syndrome is
seen by a physician who documents that the patient has
mental retardation, retinal atrophy and small head.
1. Cockayne’s Syndrome – 759.39
2. Microcephalus ( exceptionally small head) – 742.1
3. Mental Retaridation – 319
4. Retinal Atrophy – 362.60
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(Certain Conditions Originating in The Perinatal Period)
760 -779
(CASE STUDY 2)
CODE DESCRIPTION: A child was admitted for repair of cleft
lip and palate, bilateral, incomplete.
1. Cleft palate with cleft lip, bilateral, incomplete –
749.24
2. Repair of cleft lip - 27.54
3. Correction of cleft palate – 27.62
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(Certain Conditions Originating in The Perinatal Period)
760 -779
(CASE STUDY 3)
CODE DESCRIPTION: The physician documented that the
baby was small for gestational age (SGA). The baby
weighed 1850 grams. The infant was born in the hospital
by vaginal delivery.
1. Single livebirth/hospital – V30.00
2. Slow Fetus Growth – 764.07
3. Unspecified weeks of gestation – 765.20
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